Form 1 AV Survey

Grantee and/or Sub-Grantee Agency Profile																		Summary of State AV Program Data
Grantee and/or Sub-Grantee Information OMB Control No: 0970 - 0204 Expiration date: XX/XX/XXXX “A Federal agency may not conduct or sponsor, and no individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless that collection of information displays a currently valid OMB Control Number”										Service Provided &Client Participation (Values M (Mandatory), V (Voluntary) B (Both)							U, R, B	Client Referral Source							Client Information						Child Support Cases (Required)					Marital Status					Race/Ethnicity									Annual Income						Services Provided							Frequency of Service ( Hours) (Optional)							Outcome#1-Parenting Time (Required)		Outcome#2 - Knowledge of Effective Co-Parenting Strategies (Optional)
Name of Grantee and/or Sub-Grantee	Title of AV Program	Contact Name	Address Line 1	City	State	Zip	Grant Amount	Grant Period From Date	Grant Period To Date	Mediation	Development of Parenting Plan	Counseling	Parent Education	Neutral Drop-off/Pick-up	Supervised Visitation	Visitation Enforcement	Geographic Area Served	Self	Court	Child Support Agency	Domestic Violence Agency	Child Protection Agency	Other	Data Not Reported	NCP Father	CP Father	NCP Mother	CP Mother	Grandparent/Legal Guardian	Number of Children in Common	NCP Father	CP Father	NCP Mother	CP Mother	Grandparent/Legal Guardian	Never Married to Each Other	Married to Each Other	Separated From Each Other	Divorced From Each Other	Data Not Reported	American Indian or Alaska Native	Asian	Black or African American	Hispanic or Latino	Native Hawaiian or Other Pacific Islander	White	Two or More Races	Data Not Reported	Other	Less than $10,000	$10,000 to $19,999	$20,000 to $29,999	$30,000 to $39,999	$40,000 & Above	Data Not Reported	Mediation	Development of Parenting Plan	Counseling	Parent Education	Neutral Drop-off/Pick-up	Supervised Visitation	Visitation Enforcement	Mediation	Development of Parenting Plan	Counseling	Parent Education	Neutral Drop-Off/Pick-Up	Supervised Visitation	Visitation Enforcement	NCP Fathers	NCP Mothers	NCP Fathers	CP Fathers	NCP Mothers	CP Mothers
GRANTEE NUMBER 1	TITLE of AV Program 1	Mike	123 Easy Street	CITY NAME ONE	SS	12345	300000	1/20/1999	2/13/2015	B	M				M		B	0	176	0	0	0	0	2	52	30	16	74	3	135						81	38	1	50	0	1	0	31	1	0	140	0	0	5	69	70	17	8	13	1	166	90	0	0	1	0	0								50	14
GRANTEE NUMBER 2	SPACES	Bhargav	123 Slow and Annoying street	CITY NAME TWO	SS	98765	456789.5	2/13/1998	3/15/2020	V					V		R	0	176	0	0	0	0	2	52	36	16	74	3	135						81	38	1	60	0	1	0	31	1	0	144	1	0	0	69	70	17	8	13	1	166	90	0	0	1	0	0								50	14
Totals